Br. J. Surg. 1992, Vol. 79, December, 1309-1 311
Subcutaneous mastectomy w i t h immediate reconstruction as treatment for early breast cancer Subcutaneous mastectomy and axillary dissection combined with immediate reconstruction was used to treat primary breast cancer in a consecutive series of 111 patients. Local recurrence occurred in 19 patients (17 per cent) during a mean ,follow-up of 30 (range 6-60) months. Complete control of local diseuse was achieved in all patients except one, who had terminal disease. Prophylactic radiotherapy was avoided jor 83 per cent of' patients, and good cosmetic results were obtained in 89 per cent. These results support the use o j this technique in the treatment of early breast cancer.
B. V. Palmer, K. R. Mannur and W. 6. Ross Department of General Surgery, Lister Hospital, Coreys Mill Lane, Stevenage SGI 4AB, UK Correspondence to: Mr €5. V. Palmer
With the increasing incidence of early detection of carcinoma of the breast, partly caused by a heightened public awareness
and partly by screening, the debate about optimal local treatment continues. In terms of overall survival, lumpectomy provides good results for stage I and 11 breast cancer'. There has been concern about the long-term effectiveness of adjuvant radiotherapy in preventing local ~ e c u r r e n c e ~ .Cosmetic ~. results, particularly for patients with medial tumours and small breasts, can be poor. Occasionally there is considerable morbidity from radiotherapy that is difficult to treat4. New techniques of subcutaneous mastectomy with immediate reconstruction using silicone implants have improved the cosmetic results. Such results are generally good and a total clearance of breast tissue and adjacent axillary nodes can be achieved. There is no contraindication to subsequent radiotherapy.
Patients and methods A consecutive series of I 1 1 patients treated for breast cancer with subcutaneous mastectomy and immediate reconstruction between 1986 and 1990 was studied. Patient data were collected prospectively and confirmed by review of records at the time of census. Details recorded included operative procedure, histological and pathological tumour variables, adjuvant therapy and disease recurrence. Tumours were staged according to the tumour node metastasis ( T N M ) classification, with tumour size measured by the pathologist. The survival data presented are the results of life-table analyses5. Indications Subcutaneous mastectomy can be used in patients with diffuse in situ carcinoma and in those with invasive carcinoma who wish to avoid mastectomy or lumpectomy with radiotherapy. Needle biopsy and mammography are performed before surgery to enable informed discussion of treatment options. 0perutii.e technique Initially the implants were placed subpectorally in patients with little or no ptosis, but the problems of wound inflammation and rejection of the prosthesis have been overcome and nearly all prostheses are now placed subcutaneously, because of the improved cosmetic result with matching breasts. The most satisfactory incision is usually horizontal from the lateral side of the nipple. If the tumour is difficult to approach because of its medial position, then another horizontal incision is made medial to the nipple. The plane between the breast tissue and fat is opened by blunt dissection. Light skin tethering does not necessitate excision of skin if the tumour is some distance away. The subareolar ducts are divided as they enter the nipple and no nipple-everting sutures are necessary. If the nodes are not clinically involved, then the lower two-thirds of the axilla are cleared; with probable lymphatic involvement axillary dissection is performed. Care must be taken when retracting the breast skin because excessive pressure can cause fat necrosis and subsequent prolonged erythema of the overlying skin. Two suction drains are left in place.
~~~
0007 112%
121309-03
~
(
~~
~
The wound is irrigated with dilute povidone-iodine (Betadine; Napp Pharmaceuticals, Cambridge, U K ) in normal saline (1:4) to dislodge any free fat, lobules of which are sucked off the surface of the irrigation fluid. The volume of the removed breast is measured by water displacement. A trial prosthesis is placed in the pocket and the appearance compared with that of the opposite breast. All prostheses, from 75 ml to 500 ml, are low-bleed low-profile type; rough textured prostheses have recently been used6. The skin is closed in two layers, with 4/0 PDS (Ethicon, Edinburgh, U K ) to the fibrous subcuticular layer and 3/0 monofilament nylon sutures to the skin. Adhesive paper tapes are applied between skin sutures. A lateral pressure dressing is used for 48 h to keep the prosthesis in a medial position. The drains are removed when they have collected less than 10 ml on 2 consecutive days; 4 weeks is the longest that a drain has remained. Prophylactic antibiotics are administered with induction of anaesthesia and continued until the drains are removed. Patients are encouraged not to wear a brassiere for 3 months. Cupsulotomy Capsule formation was measured by a modified Baker's classification (Table I )b. Significant capsules are readily treated by open capsulotomy; a delay of 9 months after initial operation is advised to allow maximal capsular contraction. At operation the prosthesis is removed and the capsule divided with scissors around the edge, separating the base of the pocket from the dome. A small suction drain is used. Leaving the original contracted capsule in place limits the degree of further contraction, giving good long-term results.
Results Complete data were obtained for each of the 111 patients, who ranged in age from 26 to 76 (mean 51.7) years. Follow-up ranged from 6 to 60 (mean 30) months. Clinical and pathological data are shown in Table 2 . In all cases histological examination confirmed that the resection margin was free from tumour. Recurrence data are shown in Figure 1 and Table 3. Of 19 patients with local recurrence, 11 are alive and well with no residual disease, five have died from distant metastases, and three are alive but have been treated for distant or regional recurrence. When local recurrence developed, 12 patients underwent local excision and radiotherapy with local control, two underwent conversion to mastectomy followed by
Table 1
ClussiJicution qf capsule ,fornrution (modijied after Baker)
Grade
Description
19
Ideal Edges and implant palpable, no complaints or distortion Satisfactory (capsule obvious but not firm; no complaints or distortion) Inferior (capsule firm; minimal distortion, uncomfortable) Poor (firm to hard, look and feel abnormal; painful)
1B 2 3
4
~~
1992 Butterworth-Heinemann Ltd
1309
Subcutaneous mastectomy: B. V. Palmer et al. Table 2 Clinical and pathological ,features of breast cancer in 111 patients
100
-
No. of patients
Variable
1
~~
Skin tethering None Mild Marked Tumour size (cm)
Subcutaneous mastectomy w i t h immediate reconstruction as treatment for early breast cancer Subcutaneous mastectomy and axillary dissection combined with immediate reconstruction was used to treat primary breast cancer in a consecutive series of 111 patients. Local recurrence occurred in 19 patients (17 per cent) during a mean ,follow-up of 30 (range 6-60) months. Complete control of local diseuse was achieved in all patients except one, who had terminal disease. Prophylactic radiotherapy was avoided jor 83 per cent of' patients, and good cosmetic results were obtained in 89 per cent. These results support the use o j this technique in the treatment of early breast cancer.
B. V. Palmer, K. R. Mannur and W. 6. Ross Department of General Surgery, Lister Hospital, Coreys Mill Lane, Stevenage SGI 4AB, UK Correspondence to: Mr €5. V. Palmer
With the increasing incidence of early detection of carcinoma of the breast, partly caused by a heightened public awareness
and partly by screening, the debate about optimal local treatment continues. In terms of overall survival, lumpectomy provides good results for stage I and 11 breast cancer'. There has been concern about the long-term effectiveness of adjuvant radiotherapy in preventing local ~ e c u r r e n c e ~ .Cosmetic ~. results, particularly for patients with medial tumours and small breasts, can be poor. Occasionally there is considerable morbidity from radiotherapy that is difficult to treat4. New techniques of subcutaneous mastectomy with immediate reconstruction using silicone implants have improved the cosmetic results. Such results are generally good and a total clearance of breast tissue and adjacent axillary nodes can be achieved. There is no contraindication to subsequent radiotherapy.
Patients and methods A consecutive series of I 1 1 patients treated for breast cancer with subcutaneous mastectomy and immediate reconstruction between 1986 and 1990 was studied. Patient data were collected prospectively and confirmed by review of records at the time of census. Details recorded included operative procedure, histological and pathological tumour variables, adjuvant therapy and disease recurrence. Tumours were staged according to the tumour node metastasis ( T N M ) classification, with tumour size measured by the pathologist. The survival data presented are the results of life-table analyses5. Indications Subcutaneous mastectomy can be used in patients with diffuse in situ carcinoma and in those with invasive carcinoma who wish to avoid mastectomy or lumpectomy with radiotherapy. Needle biopsy and mammography are performed before surgery to enable informed discussion of treatment options. 0perutii.e technique Initially the implants were placed subpectorally in patients with little or no ptosis, but the problems of wound inflammation and rejection of the prosthesis have been overcome and nearly all prostheses are now placed subcutaneously, because of the improved cosmetic result with matching breasts. The most satisfactory incision is usually horizontal from the lateral side of the nipple. If the tumour is difficult to approach because of its medial position, then another horizontal incision is made medial to the nipple. The plane between the breast tissue and fat is opened by blunt dissection. Light skin tethering does not necessitate excision of skin if the tumour is some distance away. The subareolar ducts are divided as they enter the nipple and no nipple-everting sutures are necessary. If the nodes are not clinically involved, then the lower two-thirds of the axilla are cleared; with probable lymphatic involvement axillary dissection is performed. Care must be taken when retracting the breast skin because excessive pressure can cause fat necrosis and subsequent prolonged erythema of the overlying skin. Two suction drains are left in place.
~~~
0007 112%
121309-03
~
(
~~
~
The wound is irrigated with dilute povidone-iodine (Betadine; Napp Pharmaceuticals, Cambridge, U K ) in normal saline (1:4) to dislodge any free fat, lobules of which are sucked off the surface of the irrigation fluid. The volume of the removed breast is measured by water displacement. A trial prosthesis is placed in the pocket and the appearance compared with that of the opposite breast. All prostheses, from 75 ml to 500 ml, are low-bleed low-profile type; rough textured prostheses have recently been used6. The skin is closed in two layers, with 4/0 PDS (Ethicon, Edinburgh, U K ) to the fibrous subcuticular layer and 3/0 monofilament nylon sutures to the skin. Adhesive paper tapes are applied between skin sutures. A lateral pressure dressing is used for 48 h to keep the prosthesis in a medial position. The drains are removed when they have collected less than 10 ml on 2 consecutive days; 4 weeks is the longest that a drain has remained. Prophylactic antibiotics are administered with induction of anaesthesia and continued until the drains are removed. Patients are encouraged not to wear a brassiere for 3 months. Cupsulotomy Capsule formation was measured by a modified Baker's classification (Table I )b. Significant capsules are readily treated by open capsulotomy; a delay of 9 months after initial operation is advised to allow maximal capsular contraction. At operation the prosthesis is removed and the capsule divided with scissors around the edge, separating the base of the pocket from the dome. A small suction drain is used. Leaving the original contracted capsule in place limits the degree of further contraction, giving good long-term results.
Results Complete data were obtained for each of the 111 patients, who ranged in age from 26 to 76 (mean 51.7) years. Follow-up ranged from 6 to 60 (mean 30) months. Clinical and pathological data are shown in Table 2 . In all cases histological examination confirmed that the resection margin was free from tumour. Recurrence data are shown in Figure 1 and Table 3. Of 19 patients with local recurrence, 11 are alive and well with no residual disease, five have died from distant metastases, and three are alive but have been treated for distant or regional recurrence. When local recurrence developed, 12 patients underwent local excision and radiotherapy with local control, two underwent conversion to mastectomy followed by
Table 1
ClussiJicution qf capsule ,fornrution (modijied after Baker)
Grade
Description
19
Ideal Edges and implant palpable, no complaints or distortion Satisfactory (capsule obvious but not firm; no complaints or distortion) Inferior (capsule firm; minimal distortion, uncomfortable) Poor (firm to hard, look and feel abnormal; painful)
1B 2 3
4
~~
1992 Butterworth-Heinemann Ltd
1309
Subcutaneous mastectomy: B. V. Palmer et al. Table 2 Clinical and pathological ,features of breast cancer in 111 patients
100
-
No. of patients
Variable
1
~~
Skin tethering None Mild Marked Tumour size (cm)
